Provider Demographics
NPI:1851076731
Name:BUCHTA, JEROD THOMAS
Entity Type:Individual
Prefix:
First Name:JEROD
Middle Name:THOMAS
Last Name:BUCHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 MACON DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-9103
Mailing Address - Country:US
Mailing Address - Phone:586-663-1998
Mailing Address - Fax:
Practice Address - Street 1:1775 W HIBISCUS BLVD STE 215
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2627
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant